Afterthought: Was Immediate implant best tx plan?

Last Updated: Dec 04, 2013

First solo case, but not my first implant placement though. I have enjoyed seeing other cases here and I thought I would share my case and get some feedback. I placed a few implants (not enough!) in my Air Force training and career.

I have a 50 year old male non-smoker with deciduous T [primary tooth]with class 3 mobility. There was 4 + mm of keratinized gingival tissue. The treatment plan was to extract the tooth, place an immediate implant and graft if necessary. Final restoration would be a crown.

I made buccal/lingual sulcular incisions to distal of adjacent teeth and carefully reflected a buccal flap to view the bone structure. I extracted T and de-granulated the area. I placed an OsseoSpeed 4.5 X 11 mm implant (Astra Tech). I may have placed the implant 1 mm more apically than I planned from the CBCT™s. I apologize for the angulations in the periapical radiographs. The buccal plate was thin so I decided to graft with mineralized cancellous/cortical and covered with PTFE membrane. I sutured with 4-0 silk sutures (horizontal mattress, 3 interrupted).

I saw the patient for a 4 “day post-op and he is healing well. No facial swelling, no paresthesia, and little discomfort. I will see him in 2 weeks to remove sutures and deliver a flipper.

Looking back I wonder if grafting the area for bone loss on the mesial of #30 would have been a better tx option? I appreciate your feedback.

![]implant3d-v2](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2013/12/implant3d-v2.jpg)

![]implantguidedrill-v2](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2013/12/implantguidedrill-v2.jpg)

![]implantfinal=v2](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2013/12/implantfinalv2.jpg)

14 Comments on Afterthought: Was Immediate implant best tx plan?

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Dr. PW

12/04/2013

I think you have done well. Looking at the PA it did not look like you had many walls on the defect on the mesial of 30, so you may have been trying to gain vertical height with the graft which is tough to get predictability with. The buccal plate looks very dense on the CT, perhaps the implant could have been more slightly lingual. Personally I would not bother with the flipper if I could avoid it. I have found silk to gather alot of plaque over sites like these and prefer Vicryl (or any other PGA) or Gore-Tex. Overall nice job, I have done cases like this in the past and cover them with PRF with very nice results. Are you removing the PTFE in 4 weeks?

CRS

12/04/2013

The only thing that could have been done differently would have been to tent up the bone either with an implant or a staged procedure. Remember that with a deciduous tooth the bone level remains low since the permanent tooth never erupted bringing bone with it.Don't get why the implant is buried deep, that doesn't help the problem.Pretty please do not make a flipper you will ruin your graft, possibly expose the implant and it is not necessary!!! Essex or bonded bridges are indicated in esthetic areas for show. Think logically why would you put pressure on a healing graft?

justin

12/04/2013

Thanks for your comments! 1) It regards to implant position. It may be hard to appreciate the malposition of teeth in that segment. I placed the implant directly in center of my planned restorative space without exposing any threads of the implant. There was still a small vertical/buccal defect from the extraction of T and that's why I decided to graft. 2) In regards to height or depth, I believe the PerXR may be a little misleading. 3) I thought that a delayed flipper would be a good strategy to develop soft tissue contours and maintain the space for a 3-4 mo. I like your idea of an essex/bonded bridge though! 4) My plan was to remove the membrane at 3-4 weeks. This is my first time using PTFE membrane and I liked using it! In the past I used a resorbing collagen membrane. I had the chance to learn about and play with a chorion membrane - it looks promising but is expensive. Thanks again!

CRS

12/04/2013

Next time you may want to consider a Straumann with a transmucosal head, it will sit up and be easier to restore in the posterior mandible. The deep bone level implants are better for esthetic areas. Be wary of deciduous tooth spaces with lack of developed bundle bone not easy!

DrT

12/10/2013

Could you please explain your rationale for using non resorbable membrane? Also, considering the expense the patient is going through, I am not quite sure why you would limit your decisions on what materials to use because something is "expensive". By using a non resorbable membrane you will need to do a second procedure...isn't this adding to your expense more than if you had used an expensive resorbable membrane?

justin

12/10/2013

Thanks for your comments. 1) My rationale for using a non-resorbable membrane is difficulty of placement of resorbable (collagen) membranes that I had used in the past. Soon as they get wet they "mush up" and are difficult to keep in place. The usual protocol is to remove PTFE at 4-6 weeks which does not limit my decision based on expense. 2) Price is not a factor in my decision making. The material I used for this case cost more than a typical resorbable (collagen) membrane that I've used in the past. The only time I mentioned cost was when I was referring to a membrane (chorion) that I was recently introduced to but haven't had the chance to use. Your comments bring up a good question. Resorbable vs. non-resorbable membranes and when indicated.

DrT

12/10/2013

My advice is to stick with the resorbable membranes...I hardly no anyone who is using non resorbable membranes with GBR these days...Every technic has a learning curve...take the time and I can assure you that it won't be long before you have mastered using these materials

Richard Hughes, DDS, FAAI

12/11/2013

Justin, Dr T makes a valid point about using a resorbable membrane. There are better ressorbable membranes that have satisfactory handling characteristics and they are at a fair price. Do not put a provisional on this site, you are not really gaining anything. If the pTFE membrane gets exposed and contaminated, it could spell trouble. I suggest you spend some time investigating the membranes. I'm not trying to be a wise guy. The time will be worth it. There are several companies that are doing a good job in this department.

justin

12/11/2013

I appreciate your comments. In the past I have used HeliCOTE and Bio-Gide resorbable membranes. As I mentioned, I was looking for a membrane material that handles more predictably in my hands (I still use a resorbable membrane for my straight forward site preservations). My research led me to Cytoplast pTFE. The site claims that the membrane was designed for exposure and can be removed a 3-4 weeks without re-entering the site. The membrane is very easy to manipulate. Would you be willing to name a few resorbable membranes that are better suited? I appreciate the general consensus of not placing a provisional onto the graft! I will not be doing that.

CRS

12/14/2013

Those membranes are a pain to work with. I like the Teflon membranes if I need more stability and can't get the primary closure, easy technique excellent results. If I bury them I will remove at implant placement if there are no problems. If you are placing implants it is a surgical procedure and knowing how to atraumatically remove a non resorbable is part of the deal. However my resorbable membrane of choice is as Snoasis which is human chrorion excellent material, it stays where you place it. I'm just starting to use Sonic weld so I'm on the short end of the learning curve to comment on that one. And of course good flap with primary closure, no membrane is my standard procedure. Membranes do two things, contain graft material and prevent epithelial ingrowth. Nothing wrong with Teflon Cytoplast is a great product and has helped me many times regaining buccal plate. Also have used osteowrap which is thin cortical bone to hold the space. Cost is a consideration some of these companies have very expensive products, pericardium anyone?

DrT

12/14/2013

I just used a Bioxclude membrane on Friday for a socket preservation...if you follow their directions closely (which are very detailed and very good), then this material works great. Snoasis is a very small company (I think a total of 4 people I think), and I have found them to be extremely helpful and eager to be of assistance. No way do I want to have to remove a membrane or take the risks of membrane exposure during healing..we have already learned from this.

CRS

12/15/2013

Exposed Teflon membranes can be managed with peridex and watching the tissue granulate under it but it is much much nicer to have the control of an unexposed membrane less risk better result. I still use the Teflon if I need to preserve the vestibule and not undermine the tissue. Snoasis works great with smokers also.

DrT

12/15/2013

Peridex retards fibroblast growth...not to be used when no primary healing

justin

12/19/2013

Case Update: I removed the pTFE membrane and sutures atraumatically at 3 weeks post-op. Removal of the membrane was easy. The site looks great. I plan on leaving the site alone for awhile before placing an healing abutment and restoring. I did a site preservation today with HeliCOTE and achieved a decent result even though I'm not a huge fan of that membrane. I'm getting some samples of MatrixDerm resorbable membranes and I look forward to trying them out. Anyone using this product?

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